New Client form

South Bay Veterinary Hospital

Welcome to our South Bay Family
Owner*

First NameLast Name
Co-Owner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information - Cell Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Co-Owner Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:*
example@example.com
Owner Date of birth:*

MonthDayYear
Date
How did you here about us?
Photo Release - I hereby consent and agree that South Bay Veterinary Hospital, its employees. and/or agent have the right to take photographs or digital recordings of my pet(s) and release all rights to exhibit this work in print and electronic form publicly or privately. I also understand that South Bay Veterinary Hospital is not responsible for any expense or liability incurred as a result of the aforementioned participation in any photographs or recordings. I represent that I am at least 18 years of age, and have read and understand the foregoing statement. and am competent to execute the agreement.*

Yes, I give permission for my pet's photo to be used as noted above.No, please do not use my pet's photo.
We strive to make you a part of your pet's health care and understand you would like to be present for treatments. However, certain treatments need to be done in our treatment area. For your and your pet's safety please allow our staff to restrain your animal during examinations and transport them to the treatment area when necessary.
I understand tha I am financially responsible for all charges. If it becomes necessary to hire and outside agency to collect payment for your account, I agree to pay any and all collectiion charges, billing fees. and legal fees.

Note that an $10.00 per month fee will be appliesd to all balances on account over 30 days.
Signature of responsible party authorizing and paying for services, Please sign below.*
Date*

MonthDayYear
Date
Should be Empty:

South Bay Veterinary Hospital